Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palatka Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
Incomplete and inaccurate MDS assessments affected multiple residents. MDS entries missed or mis-coded active dx, including schizophrenia, UTI, PTSD, dementia, HTN, hyperlipidemia, and medication-related items such as scheduled pain meds, anticoagulants, antidepressants, and diuretics. Record review showed the MAR, physician orders, lab results, psychiatry notes, and care plans supported the missing or incorrect coding, and MDS staff acknowledged several errors during interview.
Ordered wound care and compression stocking use were not carried out as directed for several residents. Multiple residents were observed with wound dressings left in place beyond the ordered schedule, including dressings that were dated, soiled, or not dated/initialed, while staff and residents gave inconsistent accounts of when care was last provided. Another resident with orders for knee-high compression socks during the day and removal at night was repeatedly observed without them, and the resident stated he had not been helped to apply them for days.
Medications and topical treatments were left unattended in resident rooms and a shared bathroom, including a medication cup with cream, an antibiotic ointment, a cup of oral meds, eye drops, and unidentified creams and powder. Staff stated several residents were not able to self-administer, and the DON noted one resident had no self-administration evaluation or order allowing bedside meds.
Incomplete and inaccurate documentation of wound care, compression stocking use, and sliding-scale insulin administration was found. Several residents had wound dressings that were dated, undated, or soiled in ways that did not match the MAR/TAR, while residents and staff gave conflicting accounts about whether care was actually provided. An LPN and the DON also acknowledged documentation problems, including use of an unclear MAR code for Novolog coverage and charting compression stockings as applied when the resident said they had not been put on.
PASRR and Level II PASRR evaluations were not completed for two residents when mental illness was identified. One resident had schizophrenia and substance abuse noted on the PASRR and remained in the facility under a hospital discharge exemption, but no Level II PASRR was documented. Another resident’s PASRR did not reflect depression, even though the record later showed MDD, psychiatric notes described depressed mood, and Mirtazapine was ordered for depression; staff stated the PASRR should have been reviewed after the new diagnosis.
Failure to Include PTSD in Care Plan: A resident reviewed for behavioral management had psychiatric diagnoses including mood disorder, PTSD, depression, anxiety, TD, and opioid abuse, with notes describing trauma-related symptoms such as nightmares, flashbacks, and hypervigilance. The care plan addressed depression and anxiety but did not include PTSD, and the MDS RN Lead and DON both acknowledged that PTSD was omitted even though it should have been included.
Failure to Flush G-Tube After Bolus Feeding: An LPN administered a bolus G-tube feeding to a resident and flushed the tube before the feeding, but did not flush it afterward. The resident’s order required 50 mL of water before and after each bolus, and the DON and RD stated staff should flush before and after bolus feedings per protocol.
Respiratory care was not provided per orders for multiple residents. One resident received oxygen with humidification despite no humidifier order, another resident’s oxygen flow was observed above the ordered rate, and a third resident had a CPAP machine in use without a physician order. Staff and the DON confirmed the ordered oxygen rates should be followed and that CPAP requires an order, while the record showed no CPAP order despite a care plan reference to CPAP at HS.
A resident with major depressive disorder had a pharmacist MRR note stating Trazodone could increase drowsiness and falls, with recent falls noted, and the physician response documented agreement to discontinue. However, the MAR continued to show daily administration of Trazodone at bedtime, and the DON and physician both stated provider orders were expected to be entered and followed.
Failure to collect ordered lab specimens for two residents. One resident with COPD exacerbation had ordered iron studies that were not drawn because no requisition form was completed, and another resident’s ordered UA with micro reflex to C&S was not completed. The DON and lab representative confirmed the missing collections, and the facility policy states the designated nurse is responsible for completing the lab requisition or verifying the diagnostic appointment.
An LPN failed to perform hand hygiene and change gloves between cleansing a resident’s coccyx wound and applying new dressings, and another LPN did not don a gown while providing gastrostomy tube feeding to a resident on enhanced barrier precautions. The tube feeding was given with gloves only, and the tubing was not flushed after the bolus feed. The DON and ADON/IP confirmed the expected infection control practices.
A resident signed consent to receive the pneumococcal vaccine, but the immunization record did not show that it was administered. The DON confirmed the resident did not receive the vaccine, despite the facility policy stating residents will be offered pneumococcal vaccines unless medically contraindicated, already given, or refused.
A resident with a PICC line in the upper arm was observed with a transparent dressing that had not been changed according to the expected weekly schedule. An LPN stated that PICC dressings are supposed to be changed weekly, while another LPN indicated that the RN supervisor usually performs all PICC dressing changes but was not present. The DON confirmed that weekly PICC dressing changes are required and are the responsibility of the nurse on the cart, and acknowledged that this resident’s dressing should have been changed. There was no physician order for PICC dressing changes, despite a facility policy stating that wound care is to follow current standards of practice with physician orders documented on the Treatment Administration Record.
A resident had a physician order for daily abdominal staple wound care with normal saline and a dry dressing on the day shift, but the Treatment Administration Record lacked documentation that the ordered wound care was completed on several days. One LPN reported that dressings were changed when the resident was cared for but admitted forgetting to document on specific days, and another LPN could not recall whether the dressing was changed on one of the missing dates. This resulted in an incomplete medical record that did not accurately reflect the resident’s wound care as required by facility policy.
A resident receiving IV antibiotic therapy for a wound infection did not receive care under required enhanced barrier precautions. During a PICC line dressing change, an LPN did not wear a gown, despite the resident’s care plan directing use of enhanced barrier precautions per facility policy. The DON stated the resident should have been on enhanced barrier precautions due to the IV and wound, and that a gown should have been worn. Facility policy requires gown and glove use for high-contact care activities, including central line and wound care.
The facility failed to provide a rationale for not following pharmacy recommendations for three residents, involving medications like Oxybutynin, Gabapentin, and Rivaroxaban. Despite the pharmacist's advice to adjust or discontinue these medications due to risks like falls, the physician disagreed without justification, contrary to facility policy.
A resident with hemiplegia and other medical conditions was observed with a splint on one hand and a non-skid sock on the other, without proper authorization or documentation. Staff interviews indicated the sock's use was approved by the resident's daughter, but the facility's administrator stated it should not have been used. The facility's policy prohibits physical restraints without consent, highlighting a deficiency in policy adherence.
The facility failed to ensure accurate MDS assessments for two residents. One resident, with acute respiratory failure, was incorrectly documented as not receiving prescribed oxygen therapy. Another resident was inaccurately recorded as receiving insulin injections, despite no physician order, administration record, or diabetes diagnosis.
The facility failed to create comprehensive care plans for two residents, one with depression and behavioral issues and another with a UTI. The interdisciplinary team did not address the specific needs related to these conditions, as confirmed by the DON and Administrator.
The facility failed to administer blood pressure medication according to prescribed parameters for two residents, leading to administration errors. Additionally, a resident was left unsupervised with medication, contrary to professional standards. The DON confirmed the need for adherence to medication parameters and supervision during administration.
Two residents in the facility did not receive oxygen therapy as prescribed. One resident was observed with incorrect oxygen flow rates and without oxygen during certain activities, despite having a continuous oxygen order. Another resident received oxygen at a higher rate than prescribed. Staff interviews confirmed the discrepancies, and the facility's policy on oxygen administration was not adhered to.
A resident with chronic kidney disease was unnecessarily prescribed Sulfamethoxazole-Trimethoprim for prophylaxis without conducting a urinalysis or culture and sensitivity test to confirm a UTI. Facility staff, including the DON, APRN, and Medical Director, acknowledged the failure to follow the antibiotic stewardship policy, which requires appropriate testing before prescribing antibiotics.
Unsecured medications were found in the rooms of three residents, none of whom had self-administration orders or care plan documentation for medication self-administration. The DON confirmed that self-administration assessments were not completed, and the facility's policy requires medications to be stored in locked compartments accessible only to authorized personnel.
The facility failed to maintain proper infection control practices, as staff did not perform hand hygiene during medication administration for two residents. Additionally, respiratory equipment for two residents was not stored in bags when not in use, contrary to facility policy. Staff acknowledged these lapses, which were observed during a survey.
A resident with chronic kidney disease was prescribed antibiotics for a UTI without a urinalysis being conducted, contrary to the facility's antibiotic stewardship policy. Staff interviews revealed that antibiotics were administered without confirming a UTI through lab tests, and the facility's policy requiring diagnostic evidence before prescribing antibiotics was not followed.
The facility failed to maintain fire/smoke doors, which were found with chips, holes, and missing corners, compromising their fire protection rating. The damage was attributed to lifts and carts, as confirmed by the maintenance team. This deficiency was discussed with the facility's administration during the exit conference.
The facility failed to properly store portable oxygen cylinders, as they were found unlabeled in the soiled utility room, leading to potential confusion and delays in accessing full cylinders. Staff were unaware of this issue, indicating a lapse in oversight.
Two residents received incontinence care without proper infection control practices. A CNA did not perform hand hygiene or change gloves after applying barrier cream to a resident with multiple diagnoses, including a fracture and COPD. Another CNA failed to change gloves after peri-care before handling clean linens for a resident with conditions like acute embolism and diabetes. Both CNAs acknowledged the lapses, which violated the facility's hand hygiene and perineal care policies.
The facility failed to maintain a clean and homelike environment in one wing, with items such as blankets, cups, and gloves found on the floors of residents' rooms and bathrooms. Housekeeping services were limited to daytime hours, leaving CNAs responsible for cleaning during other shifts. The Director of Nursing confirmed these findings.
A resident with multiple health issues, including a MRSA infection and risk of falls, did not have a comprehensive care plan implemented. Observations showed missing fall mats, and the care plan lacked focus on contact isolation precautions, contrary to physician orders. This indicates a failure in meeting the resident's needs as per facility policy.
A facility failed to ensure staff used appropriate PPE for a resident on contact precautions due to MRSA. An LPN was observed in the resident's room without gloves or a gown while preparing food, contrary to the facility's policy and room signage. The resident had multiple diagnoses, including MRSA, and was under contact isolation. The DON confirmed the requirement for PPE, but the LPN did not comply.
Incomplete and inaccurate MDS assessments
Penalty
Summary
The facility failed to ensure MDS assessments were complete and accurate for multiple residents by omitting or incorrectly coding active diagnoses and medication-related items documented in the medical record. For Resident #2, the MDS Medicare 5-Day assessment did not include schizophrenia even though a physician order and MAR showed Olanzapine was administered for schizophrenia during the look-back period. For Resident #8, the Quarterly MDS did not code UTI despite physician orders for antibiotics for bacterial infection and UTI, MAR documentation of those medications, and urine culture results showing bacterial organisms. For Resident #139, the Annual MDS did not document PTSD even though a psychiatry note listed PTSD among the resident’s diagnoses and explained the symptoms and history supporting that diagnosis. Additional MDS errors involved medication and diagnosis coding. For Resident #153, the MDS incorrectly coded antidepressant, anticoagulant, and diuretic use as No even though the MAR showed administration of Remeron, Eliquis, and Lasix. For Resident #73, the 5-Day MDS coded hypertension and hyperlipidemia as No despite physician orders for metoprolol for hypertension, atorvastatin for hyperlipidemia, and supporting history and progress notes. For Resident #9, the most recent MDS included multi-drug-resistant organism and pneumonia even though staff stated these items should have been removed because they came from hospital paperwork and the resident was not being treated for pneumonia. The record also showed inaccurate coding for pain medication and anticoagulant use. For Resident #3, the 5-Day MDS did not indicate scheduled pain medication use even though the resident was receiving scheduled hydrocodone-acetaminophen for non-acute pain, and it also coded anticoagulant use as present even though the MAR did not show anticoagulant administration during the look-back period. For Resident #112, the 5-Day MDS did not document non-Alzheimer’s dementia even though a psychiatric provider note described dementia with behavioral disturbance and the care plan identified impaired cognition/dementia. Staff interviews confirmed several of these omissions and incorrect entries were not coded as documented in the residents’ records.
Failure to Provide Ordered Wound Care and Compression Stockings
Penalty
Summary
The facility failed to provide wound care dressing changes according to physician orders for multiple residents and failed to apply compression stockings as ordered for one resident. The report documents observations, interviews, and record review showing that ordered treatments were not carried out as directed, and that several wound dressings remained in place beyond the ordered change schedule or were not dated and initialed as required by facility policy. Resident #161 was observed on 7/13/2026 and again on 7/14/2026 with a dressing on the left ankle dated 7/11/2026. The resident stated that the dressing had not been changed and needed to be changed. The physician order dated 7/7/2026 directed staff to apply betadine to the left ankle and cover with Tegaderm every day shift. An LPN later stated the dressing should be changed every day, that the cart nurse was responsible if the wound doctor did not round, and that the dressing was not changed on 7/13/2026. The LPN also confirmed the dressing was still dated 7/11/2026. Resident #132 was observed with a left arm dressing that was not dated and had dark dried drainage on it, and the same condition was seen again the next day. The resident stated the nurses had not changed the dressing on the arm or leg. The record showed an order to cleanse a skin tear on the left arm, apply triple antibiotic ointment, and cover with a dry dressing every day shift. The record also showed sutures removed from the right lower leg on 7/11/2026 with a dry absorbent dressing applied, but no order documented for dressing changes for that leg wound from 7/11/2026 to 7/13/2026. Staff later stated the wound care team was responsible for Tuesday wound care and that dressings should be dated and initialed, while the DON stated dressing orders should be done as ordered and dressings should be dated and initialed. Resident #49 was observed with a gauze dressing on the left wrist that had a reddish-brown substance and was dated 7/11/2026. The resident and his wife stated the bandage had been changed on Saturday. The record showed diagnoses including dementia, repeated falls, and peripheral vascular disease, and the care plan identified risk for impaired skin integrity and a skin tear/potential skin tear. Physician orders directed cleansing and dry dressing changes for skin tears every shift. Staff later gave inconsistent accounts about whether wound care had been provided over the weekend. Resident #58 was observed with a left upper arm dressing dated 7/11/2026, and the physician order required cleansing, Medi honey, and a silicone bordered foam dressing every day shift for a skin tear. The resident stated the tape had been left on too long and had pulled skin off, and that the dressing was being changed every 2 days. Resident #150 stated that compression socks had not been put on for about 3 days and that the cardiologist had told him to wear them every day. The physician orders directed knee-high compression socks during the day and removal at night for circulation and edema. On later observation, the resident was still wearing non-slip socks, and the compression socks were found on the dresser. The resident stated he could not put them on or take them off by himself. Staff later stated the socks were supposed to be on during the day and removed at night, but the resident remained without them during observations.
Medications Left Unattended in Resident Rooms
Penalty
Summary
The facility failed to ensure medications were securely stored when unattended for residents on two of four hallways. During observations, a medication cup containing white cream was left on a resident’s nightstand while the resident stated the cream was lidocaine used for neuropathy pain, and staff later stated the resident was not able to self-administer medication and the nurse had to be present. In another room, an antibiotic ointment was observed on top of a cabinet while the resident was lying in bed, and staff stated the ointment was for the resident’s wound and should not have been left in the room. Additional observations showed a clear medication cup containing medications left on a bedside table for a resident who stated he was waiting to take them with coffee, while staff stated he was not able to self-administer and the medications should not have been left unattended. In another resident’s room, a bottle of Equate eye drops was observed on the bedside table on two separate occasions; the resident stated he wanted them in the room for dry eyes, but the DON stated an evaluation for self-administration was required and the record did not contain such an evaluation or an order allowing bedside medication storage. In a shared bathroom, medicine cups containing unidentified creams and powder were observed on the counter and in a basin, while the resident stated the creams were being used for a fungal infection and could be applied during cleaning or by the resident when the rash bothered them; physician orders showed nystatin creams ordered for multiple body areas every shift.
Incomplete and inaccurate documentation of wound care, compression stockings, and sliding-scale insulin
Penalty
Summary
The facility failed to maintain complete and accurate resident records for wound care, compression stocking use, and sliding-scale insulin administration. Surveyors observed multiple residents with wound dressings that were dated in a way that did not match the documented treatment records, or were not dated and initialed as required. In several cases, the resident stated the dressing had not been changed, while the MAR/TAR or treatment record showed the treatment as completed. Staff interviews also showed confusion about who was responsible for the wound care and whether the documented check marks meant the treatment had actually been performed. Resident #161 had a dressing on the left ankle dated 7/11 while the treatment record showed daily dressing changes documented on 7/12, 7/13, and 7/14. Resident #132 had a left arm dressing that was not dated or initialed and had dark dried drainage, yet the MAR documented wound care as completed on 7/12, 7/13, and 7/14. Resident #49 had a gauze dressing on the left wrist/forearm dated 7/11, while the MAR/TAR documented wound care each shift on 7/11, 7/12, and 7/13. Resident #58 also had a left upper arm dressing dated 7/11 even though the MAR/TAR documented daily treatment as ordered from 6/24 through 7/14, except for one refusal. The facility also documented compression stocking application for Resident #150 even though the resident stated he had not been able to get anyone to put them on for about three days and could not apply or remove them independently. On observation, he was wearing non-slip socks and the compression stockings were found in the room. In addition, Resident #7’s MAR/TAR contained multiple entries for sliding-scale Novolog where a numeric code of 9 was used on dates when blood sugars were in the range requiring insulin coverage, but there were no progress notes explaining why the ordered insulin was not given. The DON stated she could not determine what doses, if any, were administered for those occurrences, and staff acknowledged improper documentation practices.
PASRR and Level II evaluations not completed for residents with mental illness
Penalty
Summary
The facility failed to ensure Preadmission Screening and Resident Review (PASRR) and Level II PASRR evaluations were completed when mental illness was identified for two residents. One resident had a Florida PASRR dated 4/2/2026 that identified schizophrenia and substance abuse and allowed admission under a 30-day hospital discharge exemption, with a Level II evaluation required if the stay exceeded 30 days. The resident remained in the facility, but the medical record did not document that a Level II PASRR had been completed. The discharge summary also documented a significant history of schizophrenia. During interview, the Director of Social Services stated the PASRR was not clear, the history was obtained later, psych was notified, and a Level II PASRR still needed to be completed. A second resident had a Florida PASRR dated 5/5/2026 that did not document depression, but the admission record later documented major depressive disorder. Psychiatric notes described the resident as withdrawn, mildly depressed, and later diagnosed with major depressive disorder recurrent, with Mirtazapine ordered for depression. The Director of Social Services stated the MDS or psych did not notify the facility of the change in diagnosis, and the resident's PASRR should have been reviewed because of the new diagnosis of depression. The Administrator stated the system broke after changes in social services, admissions, DON, and psych.
Failure to Include PTSD in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one resident reviewed for behavioral management. Review of the resident’s psychiatric provider notes dated 4/9/2026 and 7/9/2026 documented diagnoses of mood disorder, PTSD, depression, anxiety, tardive dyskinesia, and opioid abuse. The notes stated that the resident’s PTSD history involved significant trauma with nightmares, flashbacks, and hypervigilance, causing significant distress and functional impairment, and that the symptoms had lasted more than one month without substance use or organic brain pathology. The resident’s care plan did not include a focus area for PTSD. During interview, the MDS RN Lead stated the care plan included depression and anxiety but not PTSD, and the DON stated PTSD was not included and should have been. The facility policy for the RAI Comprehensive Care Plan stated that the facility would use the RAI process to assess resident needs, develop individualized care plans, and revise them to reflect changes in resident condition.
Failure to Flush G-Tube After Bolus Feeding
Penalty
Summary
The facility failed to ensure proper flushing of a gastric tube after a bolus feeding for one resident reviewed for enteral tube management. During observation, an LPN entered the resident’s room, donned gloves but did not don a gown, flushed the resident’s gastric tube with 50 mL of water, and then administered 250 mL of Glucerna 1.5 through the G-tube. After the bolus feeding was completed, the LPN did not flush the gastric tube again. During interview, the LPN stated that she usually only flushes before to clean out the gastric tube and that the order did not say to flush after. The resident’s physician order dated 7/8/2026 directed bolus enteral feeding of Glucerna 1.5, 250 mL every 8 hours via G-tube, with 50 mL of water to be flushed before and after every bolus. The DON stated nursing staff should review orders and flush gastric tubes before and after bolus feedings, and the RD stated the nurses should flush before and after the bolus as it is the protocol. The facility policy on feeding tubes also stated to flush the feeding tube with water.
Respiratory Care Not Provided Per Orders
Penalty
Summary
The facility failed to provide respiratory care as ordered for Resident #48 and Resident #147. Resident #48 had a physician order for oxygen at 4 liters per minute via nasal cannula every shift, but observations on 07/13/2026 and 07/14/2026 showed oxygen being administered with humidification attached, and the record did not contain an order for humidification. Staff stated the resident did not have a humidifier ordered, that the flow rate should be checked every shift, and that humidification would be used if the resident had a dry nose or nosebleeds, with the provider notified and documentation made. Resident #147 had a physician order for oxygen at 2 liters per minute via nasal cannula every shift, but multiple observations showed oxygen being administered at 3 liters per minute. During an observation with an LPN, the flow rate was confirmed to be 3 liters per minute and the LPN stated the flow rate was wrong. The DON stated nurses are to check the flow rate throughout the shift to make sure it is accurate. The facility policy for oxygen administration stated to start the flow of oxygen at the prescribed rate. The facility also failed to obtain a physician order for Resident #84’s CPAP machine. Resident #84 had COPD and heart failure, and a CPAP machine was observed in the room on multiple occasions along with a nebulizer machine and tubing. The resident stated the CPAP had been used for a long time and came from home. Staff stated an order is needed for CPAP and that if there is no order, medical records should be reviewed for hospital information and sleep study details. The record contained a care plan referencing CPAP at bedtime, but there was no physician order for the CPAP machine, and the MDS did not document CPAP use.
Physician Order for Psychoactive Medication Not Followed
Penalty
Summary
The facility failed to ensure physician orders were followed related to the pharmacy Psychoactive Medication Use Recommendations for Resident #49, who had a diagnosis of major depressive disorder, recurrent, moderate. The consultant pharmacist’s monthly drug regimen review dated 6/23/2026 noted that the resident was receiving Trazodone, which could increase the risk of drowsiness and falls, and referenced recent falls. The recommendation asked that the medication be evaluated and that tapering the dose or an alternative treatment be considered if necessary. The physician response was documented as “Agree; Will do; D/C.” Despite that documented response, the resident’s physician order dated 6/22/2026 remained Trazodone HCl 25 mg by mouth at bedtime, and the MAR from 6/23/2026 through 7/15/2026 showed the medication was administered daily at bedtime by nurse initials. During interviews, the DON stated the pharmacist’s recommendations were reviewed by the MD or NP and any resulting changes were to be entered into the EMR by the Unit Managers, and the expectation was that provider orders would be entered and followed. The physician stated that when he or a nurse practitioner wrote a medication order, it was to be followed. The facility policy stated that consultant pharmacist recommendations were to be reported timely and followed up to ensure safe and appropriate medication utilization.
Failure to Collect Ordered Laboratory Specimens
Penalty
Summary
The facility failed to ensure ordered laboratory specimens were collected for 2 residents reviewed for laboratory services. For one resident with COPD with an acute exacerbation, the physician ordered Ferritin, Folate, Iron, TIBC, and % saturation to be sent one time only, but the medical record did not contain results for those ordered labs. During interview, the DON stated the resident’s labs did not get drawn and the facility did not do a requisition form. For another resident, the physician ordered a urinalysis with microscopic reflex to urine culture as a one-time order, but the medical record did not contain lab results for that order. During interview, the DON stated the urinalysis was not completed. The lab representative stated the resident did not have the ordered labs drawn and that the last labs on record were prior CBC and CMP results. The facility policy stated the designated nurse is responsible for completing the lab requisition or verifying the diagnostic procedure appointment has been made when the order is noted.
Infection control failures during wound care and tube feeding
Penalty
Summary
The facility failed to prevent the possible spread of infection during wound care for Resident #6. During observation of wound care, an LPN performed hand hygiene and donned a gown and clean gloves, then set up wound care supplies and placed them on the resident’s bedside table. After doffing gloves and performing hand hygiene, the LPN applied clean gloves and cleansed the resident’s coccyx wound with wound cleanser. The LPN then patted the area dry with gauze, but did not remove the soiled gloves, did not perform hand hygiene, and did not don clean gloves before packing the wound with mupirocin, Santyl, and calcium alginate and covering it with a silicone foam dressing. The LPN later stated she was not aware she needed to wash her hands and change gloves between cleaning the wound and applying the new wound dressings. The DON stated the nurse should have washed her hands and changed gloves after cleaning the wound before applying a new dressing. The facility also failed to follow enhanced barrier precautions during administration of a gastrostomy tube feeding for Resident #136. During observation, an LPN entered the resident’s room, donned gloves, but did not don a gown even though the room door had an enhanced barrier sign. The LPN administered 50 mL of water to flush the gastric tube and then gave 250 mL of Glucerna 1.5 by bolus feeding, but did not flush the tubing after the feeding was completed. The DON stated staff should have donned a gown to provide a bolus feeding via the feeding tube, and the ADON/Infection Preventionist stated that when a resident is on enhanced barrier precautions, staff should don gloves and a gown to provide direct care. The LPN later stated she should have donned a gown to provide care to the resident.
Missing Pneumococcal Vaccination Documentation
Penalty
Summary
The facility failed to ensure that Resident #43’s health record showed receipt of the pneumococcal immunization. Review of the resident’s vaccination records showed a pneumococcal immunization consent signed on 8/25/2025 indicating acceptance of the vaccine, but the immunization report did not document that the vaccine was actually administered. During an interview on 7/16/2026 at 1:21 PM, the DON stated that Resident #43 did not receive the pneumococcal vaccination. The facility policy titled, Pneumococcal Vaccine, states that all residents will be offered pneumococcal vaccines and that the vaccines will be administered unless medically contraindicated, already given, or refused.
Failure to Perform Timely PICC Line Dressing Changes per Standards of Practice
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV therapy by not performing Peripherally Inserted Central Catheter (PICC) dressing changes according to professional standards for one resident. During observation, the resident was noted to have a PICC line in the right upper arm with a transparent dressing dated 2/11, indicating it had not been changed weekly as required. An LPN stated that PICC dressings are supposed to be changed weekly, believed to be on Saturdays, and another LPN reported that the RN supervisor typically changes all PICC dressings but was not present that day. The Director of Nursing confirmed that PICC dressings should be changed every week and that it is the responsibility of the nurse on the cart, acknowledging that this resident’s dressing should have been changed and that there was no physician order for PICC dressing changes. Review of the facility’s skin and wound management policy showed that wound care is to be managed based on current standards of practice, with a physician order documented on the Treatment Administration Record when skin impairment is identified, but no such order existed for this resident’s PICC dressing care. These findings demonstrate that the facility did not follow its own policy and professional standards regarding PICC line dressing changes and lacked appropriate physician orders for this aspect of the resident’s IV therapy care.
Failure to Accurately Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure complete and accurate documentation of wound care treatments in the medical record for one resident. Resident #1 had a physician’s order dated 01/17/2026 for daily abdominal staple wound care with normal saline, pat dry, and application of a dry dressing on the day shift through 01/26/2026. Review of the Treatment Administration Record showed no documentation that the ordered abdominal wound care was completed on 01/18/2026, 01/19/2026, or 01/23/2026. In interview, one LPN stated she changed the resident’s abdominal dressing whenever she cared for the resident but acknowledged she must have forgotten to document the dressing changes on 01/18 and 01/23, while another LPN could not recall whether the dressing was changed on 01/19. The facility’s documentation policy requires clinical staff to document care and services in a manner that accurately reflects the clinical care provided and provides a complete account of the resident’s care, treatment, and response.
Failure to Use Enhanced Barrier Precautions During PICC Line Dressing Change
Penalty
Summary
The facility failed to implement its infection prevention and control program by not using enhanced barrier precautions during intravenous therapy care for Resident #2. On 02/27/2026 at 10:32 AM, an LPN was observed changing Resident #2’s PICC line dressing without wearing a gown. Resident #2 had an IV for antibiotic medications related to a wound infection, and the resident’s care plan dated 02/02/2026 specified that enhanced barrier precautions were to be provided per facility policy. The Director of Nursing stated that Resident #2 should be on enhanced barrier precautions due to the IV and wound, and that the LPN should have worn a gown, while also noting that there was no order for enhanced barrier precautions. The LPN reported not thinking a gown was needed to change a PICC line dressing. Review of the facility’s Enhanced Barrier Precautions policy showed that gown and glove use is required for high-contact resident care activities, including device care such as central lines and wound care for any skin opening requiring a dressing.
Failure to Provide Rationale for Disagreement with Pharmacy Recommendations
Penalty
Summary
The facility failed to provide a rationale when actions were not taken for pharmacy recommendations for three residents reviewed for unnecessary medication. For Resident #7, the consultant pharmacist recommended tapering or discontinuing Oxybutynin and Hydrocodone/APAP due to increased fall risk, but the physician disagreed without providing a rationale. The facility's policy requires that each resident's drug regimen be managed to promote their highest practicable wellbeing, yet the physician's responses lacked the necessary justification. Resident #84 was receiving Gabapentin and Guaifenesin without a stop date, both of which were flagged by the pharmacist for potential risks and lack of necessity. The physician disagreed with the pharmacist's recommendations to taper or add a stop date without providing a rationale. The Director of Nursing confirmed that the provider should document a reason for disagreement, but this was not done, indicating a failure to adhere to the facility's policy on drug regimen management. For Resident #99, multiple pharmacist recommendations were made regarding the timing and dosage of medications such as Rivaroxaban, Methotrexate, and Lorazepam, as well as the use of Duloxetine with a low creatinine clearance level. In each case, the physician disagreed with the recommendations without providing a rationale. Interviews with the Director of Nursing revealed that while the recommendations were reviewed, the required rationale for disagreement was not documented, which is contrary to the facility's policy aimed at ensuring residents' wellbeing.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by the use of a non-skid sock on the resident's hand without proper authorization or documentation. The resident, who was admitted with medical diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, and contracture of the left hand, was observed on multiple occasions with a splint on her left hand and a non-skid sock on her right hand. These observations were made over several days, and there were no physician orders or consent forms authorizing the use of such devices as restraints. Interviews with staff revealed that the use of the sock was either requested or approved by the resident's daughter, but the facility's administrator confirmed that the resident should not have had a sock on her hand. The facility's policy on physical restraints clearly states that no physical restraint should be imposed on any resident for discipline or convenience, and defines physical restraints as any device that restricts freedom of movement or normal access to one's body. The lack of proper documentation and consent for the use of the sock as a restraint indicates a deficiency in the facility's adherence to its own policies and procedures regarding the use of physical restraints.
Inaccurate MDS Assessments for Oxygen Therapy and Insulin
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. Resident #4, who was admitted with acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and acute posthemorrhagic anemia, had a physician's order for continuous oxygen therapy at 3 liters per minute via nasal cannula. However, the MDS assessment dated 12/24/2024 incorrectly indicated that the resident was not receiving oxygen therapy. Additionally, Resident #143's MDS assessment dated 11/25/2024 inaccurately documented that the resident received insulin injections over the last seven days, despite the absence of a physician's order for insulin, no insulin administration recorded in the Medication Administration Record for November 2024, and no diagnosis of Diabetes Mellitus.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident #21, who has a history of depression, dementia, and insomnia, did not have a care plan that addressed potential behaviors related to these diagnoses. Despite documented instances of the resident refusing care, such as showers and lab tests, and being on psychiatric medications, the interdisciplinary team did not create a care plan focusing on these behaviors or the resident's use of antidepressants. The Director of Nursing acknowledged that a care plan should have been initiated to address these issues. Similarly, Resident #44, who was diagnosed with a urinary tract infection (UTI), did not have a care plan that included the UTI diagnosis or the prescribed antibiotic therapy. The resident was ordered Macrobid for the UTI, but the interdisciplinary team failed to document a care plan for this condition or the associated treatment. The facility's Administrator confirmed that the team was responsible for identifying and care planning for the UTI and antibiotic therapy, which was not done.
Medication Administration Errors and Lack of Supervision
Penalty
Summary
The facility failed to administer blood pressure medication according to the prescribed parameters for two residents. Resident #103 was given Metoprolol Tartrate despite having systolic blood pressure readings below the prescribed threshold of 120 on multiple occasions in January and February 2025. The Director of Nursing acknowledged that the medication was administered outside of the parameters and emphasized the need for staff to follow the provider's orders and seek clarification if needed. The Medical Director confirmed that there were no adverse medical issues resulting from this administration error. Resident #143 received Midodrine despite having systolic blood pressure readings above the prescribed threshold of 110. The medication was administered on several occasions in January and February 2025 when the blood pressure readings were higher than the specified limit. The Director of Nursing stated that nurses are expected to administer medication according to the parameters and seek clarification from the physician if needed. It was noted that the medication order for Resident #143 was a transcription error, which should have indicated holding the medication for systolic blood pressure greater than 130. Additionally, the facility failed to follow professional standards of practice during medication administration for Resident #456. The resident was found holding a medication cup with tablets and a capsule without a nurse present in the room. The nurse was attending to a computer screen outside the room, contrary to the expectation that nurses should observe residents taking their medications. The Director of Nursing confirmed that the nurse should have stayed in the room until the resident had taken the administered medications.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility staff failed to administer oxygen therapy according to professional standards for two residents. Resident #8 was observed on multiple occasions with incorrect oxygen flow rates. On one occasion, the resident was seen at the nurse's station without any oxygen therapy, despite having a physician's order for continuous oxygen at 2 liters per minute (LPM) via nasal cannula for shortness of breath. Interviews with staff revealed a lack of adherence to the prescribed oxygen flow rate, with the Director of Nursing stating that residents should be kept on the prescribed flow at all times, and the Activities Assistant confirming that the resident was not on oxygen during certain activities. Similarly, Resident #125 was observed receiving oxygen at 3 LPM, contrary to the physician's order of 2 LPM via nasal cannula. The resident mentioned that the nurse had changed the flow rate and tubing, but they did not adjust the machine themselves. A registered nurse confirmed the incorrect flow rate and adjusted it after checking the resident's orders. The Director of Nursing emphasized the importance of monitoring and maintaining the correct flow rate. The facility's policy on oxygen administration specifies that oxygen should be started at the prescribed rate, which was not followed in these cases.
Failure to Adhere to Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary antibiotic use, specifically concerning the administration of Sulfamethoxazole-Trimethoprim (Bactrim DS) for prophylaxis. The resident, who had a diagnosis of chronic kidney disease stage 4, was prescribed Bactrim DS for seven days following a report of painful urination. However, there was no urinalysis (UA) or culture and sensitivity (C&S) test conducted to confirm the presence of a urinary tract infection (UTI) before the antibiotics were administered. The facility's policy on antibiotic stewardship, which requires a complete assessment and appropriate testing before prescribing antibiotics, was not followed in this case. Interviews with the facility's staff, including the Director of Nursing, Advanced Practice Registered Nurse, Infection Preventionist, and Medical Director, revealed a lack of adherence to the facility's antibiotic stewardship policy. The staff acknowledged that antibiotics were started without obtaining a UA, and the Medical Director admitted to ordering the antibiotics without ordering labs. The Infection Preventionist noted that the facility's policy was not followed, and the antibiotics should have been discontinued if the UA was negative. This oversight in following the established protocol for antibiotic use led to the unnecessary administration of antibiotics to the resident.
Unsecured Medications Found in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional standards, as unsecured medications were observed in resident rooms. During observations, a bottle of Fluticasone Propionate Lotion was found on a bedside table of a resident who did not have a self-administration order or care plan focus for medication self-administration. Similarly, a circular white tablet was found in a medication cup on another resident's bedside table, and four circular white tablets were found on a third resident's bedside table. None of these residents had physician orders or care plans documenting a focus for medication self-administration. The Director of Nursing acknowledged that self-administration assessments were not completed for the residents involved and stated that nursing staff should remain with residents to ensure medication is taken and not left unattended. The facility's policy requires that all medications, except for Emergency Drug Kits, be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. This policy was not adhered to, leading to the observed deficiencies.
Infection Control and Equipment Storage Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with hand hygiene protocols during medication administration. Specifically, a Registered Nurse (RN) was observed administering intravenous medication to a resident without performing hand hygiene before donning gloves or after removing them. Similarly, a Licensed Practical Nurse (LPN) was seen preparing and administering oral medications to another resident without using hand hygiene. Both staff members acknowledged their failure to adhere to the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent infection spread. Additionally, the facility did not adhere to acceptable standards for storing respiratory care equipment. Observations revealed that nebulizer masks and nasal cannulas were not stored in bags when not in use, contrary to the facility's policy. This was noted in the cases of two residents, where respiratory equipment was left exposed on bedside tables or floors. Interviews with nursing staff and the Director of Nursing confirmed that such equipment should be bagged when not in use to prevent nosocomial infections, as outlined in the facility's respiratory therapy equipment policy.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol by not adequately monitoring the use of antibiotics for a resident with a urinary tract infection (UTI). The resident, who had a diagnosis of chronic kidney disease stage 4, was prescribed Bactrim DS for prophylaxis without a urinalysis (UA) being conducted to confirm the presence of a UTI. The medication administration record showed that the resident received 13 doses of the antibiotic over a period of seven days. Interviews with facility staff revealed a lack of adherence to the facility's antibiotic stewardship policy. The Director of Nursing acknowledged that a UA should have been collected, and the Advanced Practice Registered Nurse admitted to an oversight in not ordering the UA. The Infection Preventionist and Medical Director both indicated that antibiotics were started without confirming a UTI through laboratory tests, which is contrary to the facility's policy that emphasizes the need for a UA and culture and sensitivity (C&S) before starting antibiotics. The facility's policy on antibiotic stewardship and clinical protocol for UTIs were not followed, as antibiotics were prescribed and administered without complete diagnostic evidence. The policy requires that antibiotics be prescribed with a clear indication of use, including a start and stop date, and that treatment decisions be based on clinical signs and symptoms. The failure to conduct a UA and C&S before administering antibiotics led to a breach in the facility's protocol, as confirmed by staff interviews and record reviews.
Facility Fails to Maintain Fire/Smoke Doors
Penalty
Summary
The facility failed to maintain the integrity of fire/smoke doors, which are crucial for resisting the passage of smoke and providing fire protection. During a facility tour, it was observed that the fire/smoke doors had chips and holes, with some doors missing entire corners, allowing visibility into the next room. This condition compromises the fire protection rating of the doors, as the exposed door cores provide less fire resistance than required. The issue was confirmed during an interview with the Regional Maintenance Director, Maintenance Director, and Assistant Maintenance Director, who acknowledged that the damage was caused by lifts and carts frequently tearing up the doors. These findings were discussed with the facility's administration and maintenance team during the exit conference, highlighting the facility's failure to maintain the required standards for fire/smoke doors as per NFPA 101 and NFPA 80 regulations.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to maintain proper storage of portable oxygen cylinders, specifically E Cylinders, as observed during a facility tour. The cylinders were found in various areas of the soiled utility room without appropriate labeling to distinguish between full and empty cylinders. This lack of labeling could lead to confusion and delays in accessing a full cylinder when needed urgently. During interviews with the Regional Maintenance Director, Maintenance Director, and Assistant Maintenance Director, it was revealed that they were unaware of the improper storage practices. The findings were confirmed by these staff members, indicating a lapse in oversight and adherence to the NFPA 99 (2012 Edition) standards, specifically CH 11.6.5.3, which requires empty cylinders to be marked to avoid confusion.
Infection Control Lapses During Incontinence Care
Penalty
Summary
The facility failed to adhere to infection control practice standards during incontinence care for two residents. Resident #5, who has multiple diagnoses including a displaced intertrochanteric fracture and chronic obstructive pulmonary disease, was observed receiving incontinence care from a CNA who did not perform hand hygiene before donning gloves. The CNA removed the soiled brief, applied barrier cream, and placed a clean brief and under pad on the resident without changing the soiled gloves. The CNA acknowledged the mistake during an interview, stating that handwashing and glove changing should have occurred after applying the barrier cream. Similarly, Resident #6, with diagnoses such as acute embolism and type 2 diabetes mellitus, was also subject to improper infection control practices. During incontinence care, another CNA failed to change gloves after performing peri-care and before handling clean linens. The CNA admitted to not following proper infection control procedures, which included changing gloves and washing hands after completing peri-care. The facility's policies on perineal care and hand hygiene emphasize the importance of handwashing and glove changing to prevent infections, which were not adhered to in these instances.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its wings, as observed during a facility tour. Specific deficiencies included a blanket on the floor near the window and a plastic cup under the bedside table in a resident's room, a medication cup on the floor in another resident's room, and a plastic cup and blue glove on the bathroom floor shared by two residents. Additionally, there was a dried brown substance on the toilet and a towel on the floor under the sink in another resident's room. Interviews with staff revealed that housekeeping services were only available during the day shift, leaving CNAs responsible for cleaning during other shifts. The Director of Nursing confirmed these findings.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for a resident, leading to deficiencies in care. The resident, who was admitted with multiple diagnoses including a dislocated hip, chronic ulcers, and a MRSA infection, was identified as being at risk for falls. Despite this, observations revealed that fall mats, which were part of the resident's care plan interventions, were not present by the resident's bed. This was confirmed by a Licensed Practical Nurse during an observation and interview, indicating a failure to implement the care plan interventions. Additionally, the resident was under contact isolation precautions due to a MRSA infection, as per a physician's order. However, the care plan did not include a focus on contact isolation precautions, which was verified by the Director of Nursing. The facility's policy on person-centered care planning requires that care plans be individualized and comprehensive, addressing the resident's medical, nursing, and psychosocial needs. The absence of these critical elements in the care plan highlights a deficiency in meeting the resident's needs.
Failure to Use PPE for Resident on Contact Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) while providing direct care to residents on contact precautions, specifically for a resident with a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. During an observation, a Licensed Practical Nurse (LPN) was seen in the resident's room without wearing gloves or a gown while preparing food, despite clear signage indicating the need for such precautions. The signage instructed everyone to clean their hands before entering and upon leaving the room, and for providers and staff to wear gloves and a gown before room entry and discard them before room exit. The resident involved had multiple diagnoses, including a MRSA infection, and was under contact isolation precautions as per a physician's order. The facility's policy on transmission-based precautions, revised in September 2022, required staff and visitors to wear gloves and a disposable gown upon entering the room. The Director of Nursing confirmed that staff are supposed to follow these precautions when residents are on specific isolation. However, the LPN admitted to not wearing the required PPE, stating it was only necessary when providing direct care, despite the resident's MRSA status.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palatka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Radiant Nursing And Rehab At Palatka | 1.8 mi | ★★★★★ | 11 | 0 |
| The Pavilion At Crescent Lake | 18.7 mi | ★★★★★ | 13 | 0 |
| Aviata At Green Cove Springs | 23.4 mi | ★★★★★ | 0 | 0 |
| Pavilion For Health Care, The | 23.8 mi | ★★★★★ | 0 | 0 |
| Moultrie Creek Nursing And Rehab Center | 24.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.